Gamma Knife stereotactic radiosurgery for idiopathic trigeminal neuralgia

Clinical article

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Object

Trigeminal neuralgia pain causes severe disability. Stereotactic radiosurgery is the least invasive surgical option for patients with trigeminal neuralgia. Since different medical and surgical options have different rates of pain relief and morbidity, it is important to evaluate longer-term outcomes.

Methods

The authors retrospectively reviewed outcomes in 503 medically refractory patients with trigeminal neuralgia who underwent Gamma Knife surgery (GKS). The median patient age was 72 years (range 26–95 years). Prior surgery had failed in 205 patients (43%). The GKS typically was performed using MR imaging guidance, a single 4-mm isocenter, and a maximum dose of 80 Gy.

Results

Patients were evaluated for up to 16 years after GKS; 107 patients had > 5 years of follow-up. Eighty-nine percent of patients achieved initial pain relief that was adequate or better, with or without medications (Barrow Neurological Institute [BNI] Scores I–IIIb). Significant pain relief (BNI Scores I–IIIa) was achieved in 73% at 1 year, 65% at 2 years, and 41% at 5 years. Including Score IIIb (pain adequately controlled with medication), a BNI score of I–IIIb was found in 80% at 1 year, 71% at 3 years, 46% at 5 years, and 30% at 10 years. A faster initial pain response including adequate and some pain relief was seen in patients with trigeminal neuralgia without additional symptoms, patients without prior surgery, and patients with a pain duration of ≤ 3 years. One hundred ninety-three (43%) of 450 patients who achieved initial pain relief reported some recurrent pain 3–144 months after initial relief (median 50 months). Factors associated with earlier pain recurrence that failed to maintain adequate or some pain relief were trigeminal neuralgia with additional symptoms and ≥ 3 prior failed surgical procedures. Fifty-three patients (10.5%) developed new or increased subjective facial paresthesias or numbness and 1 developed deafferentation pain; these symptoms resolved in 17 patients. Those who developed sensory loss had better long-term pain control (78% at 5 years).

Conclusions

Gamma Knife surgery proved to be safe and effective in the treatment of medically refractory trigeminal neuralgia and is of value for initial or recurrent pain management. Despite the goal of minimizing sensory loss with this procedure, some sensory loss may improve long-term outcomes. Pain relapse is amenable to additional GKS or another procedure.

Abbreviations used in this paper: BNI = Barrow Neurological Institute; GKS = Gamma Knife surgery; MVD = microvascular decompression; PRGR = percutaneous retrogasserian glycerol rhizotomy; RFL = radiofrequency lesioning.

Article Information

Address correspondence to: Douglas Kondziolka, M.D., M.Sc., F.R.C.S.C., Department of Neurological Surgery, University of Pittsburgh, Suite B-400, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213. email: kondziolkads@upmc.edu.

Please include this information when citing this paper: published online September 11, 2009; DOI: 10.3171/2009.7.JNS09694.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Kaplan-Meier estimate of the probability of initial pain relief (BNI Score I–IIIb) and of initial complete pain relief (BNI Score I) after GKS.

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    Kaplan-Meier estimates. Upper: The probability of initial pain relief after GKS showing a faster time to relief in patients with TN Type I (p = 0.014). Lower: The probability of initial pain relief after GKS showing a faster time to relief in patients with no prior surgery (p = 0.014).

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    Kaplan-Meier estimate of maintaining significant pain relief (BNI Scores I–IIIa).

  • View in gallery

    Kaplan-Meier estimates of the probability of maintaining adequate pain relief (BNI Scores I–IIIb) after GKS predicting a higher recurrence rate in patients with additional symptoms (p = 0.019) (upper) and in patients with ≥ 3 failed surgeries (p = 0.033) (lower).

  • View in gallery

    Kaplan-Meier estimate of the probability of maintaining adequate pain relief (BNI Scores I–IIIb) after GKS predicting a lower recurrence rate in patients with new facial sensory dysfunction (p < 0.0001).

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